Analisis Kualitatif Dokumen Rekam Medis Rawat Inap Pada Pasien

Tuberkulosis Paru Di RSUD Tongas Probolinggo Triwulan I Tahun 2017

Qualitative Analysis of Inpatient Medical Record Document on Pulmonary
Tuberculosis Patient in RSUD Tongas Probolinggo 1st Quarter of 2017

Mitha Audia Rachma

Study Program of Medical Record
Majoring of Health

ABSTRACT

Qualitative analysis is a review of medical record related to the consistency of

medical record content. A good medical record (MR) should contain complete
medical record documents (MRD). This study was aimed to analyze the
qualitative medical records document of inpatients with pulmonary tuberculosis at
RSUD Tongas Probolinggo on the first quarter of 2017. The type of this research
is descriptive with qualitative approach using observation and interview data
collection techniques. The result of this research is there are still some incomplete
and inaccurate documents of medical record of pulmonary tuberculosis patients
at RSUD Tongas Probolinggo. One of the incomplete data was found in
qualitative administrative analysis of patient’s address which are not 100%
complete. This problem occurs because the nurse doesn’t pay much attention on
the completion of patient’s data and often forget to remind the patient or patient’s
family/guard to fill the informed consent sheet. Besides, the medical staff did not
apply 100% of the abbreviation of the standard of tuberculosis contained in SOP
stands for RSUD Tongas Hospital, due to the lack of socialization from the MR
unit to the medical personnel related to the abbreviation of the standard of
tuberculosis. In medical qualitative analysis, there is no result of X-ray
examination of patient who conducted X-ray examination as many as 19
documents, because RSUD Tongas does not have examination result sheet, so that
the examination result is not written in MRD. Therefore, the quality of pulmonary
tuberculosis patients’ MRD both administratively and medically are considered
not good. To overcome this problem, precision and discipline of medics is
required in filling the MRD.

Keywords: Qualitative Analysis, Document Record Medical, Pulmonary

Tuberculosis.

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